Colonoscopy-induced splenic injury: report of 3 cases and literature review

Subdiaphragmatic phrenic nerve supply: A systematic review

OBJECTIVE

The aim of this systematic review is to study the subdiaphragmatic anatomy of the phrenic nerve.

MATERIALS AND METHODS

A computerised systematic search of the Web of Science database was conducted. The key terms used were phrenic nerve, subdiaphragmat*, esophag*, liver, stomach, pancre*, duoden*, intestin*, bowel, gangli*, biliar*, Oddi, gallbladder, peritone*, spleen, splenic, hepat*, Glisson, falciform, coronary ligament, kidney, suprarenal, and adrenal. The 'cited-by' articles were also reviewed to ensure that all appropriate studies were included.

RESULTS

A total of one thousand three hundred and thirty articles were found, of which eighteen met the inclusion and exclusion criteria. The Quality Appraisal for Cadaveric Studies scale revealed substantial to excellent methodological quality of human studies, while a modified version of the Systematic Review Centre for Laboratory Animal Experimentation Risk of Bias Tool denoted poor methodological quality of animal studies. According to human studies, phrenic supply has been demonstrated for the gastro-esophageal junction, stomach, celiac ganglia, liver and its coronary ligament, inferior vena cava, gallbladder and adrenal glands, with half of the human samples studied presenting phrenic nerve connections with any subdiaphragmatic structure.

CONCLUSIONS

This review provides the first systematic evidence of subdiaphragmatic phrenic nerve supply and connections. This is of interest to professionals who care for people suffering from neck and shoulder pain, as well as patients with peridiaphragmatic disorders or hiccups. However, there are controversies about the autonomic or sensory nature of this supply.

Splenic Injury After Colonoscopy in a 55-Year-Old Female Patient

Colonoscopy is, in general, a relatively safe procedure with a low complication rate. Splenic injury related to this procedure is very rare, ranging from one in 100,000 to one in 6,387 colonoscopies, but a possibly lethal complication. For its diagnosis, a high degree of clinical suspicion is needed as many physicians are not aware of its existence. Clinical symptoms and signs are observed 1-10 days after the procedure. The imaging modality of choice is contrast-enhanced computed tomography (CECT). However, contrast-enhanced ultrasound (CEUS) may also be used to detect abdominal fluid and the injured area of the spleen. We present a case of a 55-year-old female with splenic rupture after a colonoscopy, diagnosed with CEUS and CECT. Splenectomy was performed, and the patient's recovery was uneventful.

A Systematic Review on Spinal Asymmetries in Case Studies of Unilateral Nephroptosis from a Viscerosomatic Point of View

The assessment of posture and asymmetries is common in musculoskeletal clinical practice, and correction is a frequent goal. In this setting, posture and asymmetries are usually interpreted in terms of musculoskeletal issues. This study aimed to evaluate spinal asymmetries in case studies of unilateral nephroptosis. A systematic review was performed using PubMed, CINAHL, Scopus and Web of Science. We included case reports and case series of nephroptotic patients which showed diagnostic imaging that allowed us to assess the presence of spinal asymmetries in the frontal plane. The methodological quality of the selected studies was assessed by using Case Report (CARE) checklist. Nineteen studies were included, with a total number of 78 reported patients (69 women) ranging 22 to 44 years old (mean: 29). Only one patient presented with medial nephroptosis, while the rest presented with caudal migration. Ninety-one percent of the cases affected to the right kidney. All cases but two showed homolateral flank closure (lower rib descent, iliac crest raise and/or homolateral side-bending). The correction of nephroptosis, either by supine position or surgical treatment, removed asymmetries in some cases while other cases improved only partly. Manual therapists must consider visceral implications while assessing body posture. Further, since the most common symptom of nephroptosis is loin pain, and it has been claimed that loin pain is underdiagnosed, manual therapists should consider its potential presence during clinical practice. Finally, being that nephroptosis shares several features with idiopathic lumbar scoliosis (type of patient, postural adaptation), more research is needed regarding any possible relation between them.

Hemoperitoneum with Splenic Artery Rupture Following Diagnostic Colonoscopy

Colonoscopy is a safe and extremely popular diagnostic and therapeutic procedure. The most common complications are bleeding and perforation. Hemoperitoneum is a rare complication after a colonoscopy and is usually associated with splenic injury or solid organ pathology. This is potentially serious and can be life threatening. With the increasing number of colonoscopies performed, there has also been an increasing trend in reports of rare complications, such as pneumothorax, pneumomediastinum, appendicitis, small bowel perforation, septicemia, mesenteric tear, retroperitoneal abscess, and hemoperitoneum. This paper reports a unique case of hemoperitoneum after a recent colonoscopy without a splenic rupture or intra-abdominal abnormality, or external trauma. Most hemoperitoneum occurs within 48 hours after the inciting colonoscopy. In the present case, however, hemoperitoneum appeared 10 days after the colonoscopy. This case emphasizes that physicians should consider hemoperitoneum in a differential diagnosis of abdominal pain in patients after colonoscopy.

Visceral Origin: An Underestimated Source of Neck Pain. A Systematic Scoping Review

The diagnosis of neck pain is challenging. Many visceral disorders are known to cause it, and clinical practice guidelines recommend to rule them out during neck pain diagnosis. However, the absence of suspicion of any cause impedes one from establishing that specific aetiology as the final diagnosis. To investigate the degree of consideration given to visceral aetiology, a systematic search of trials about neck pain was carried out to evaluate their selection criteria. The search yielded 309 eligible articles, which were screened by two independent reviewers. The PEDro scale score was used to assess the methodological quality of the studies. The following information was retrieved: number of authors affiliated to a clinical or non-clinical institution, number of citations in the Web of Science, study aims, characteristics of participants, and eligibility criteria. The top 15 most cited trials, and the 15 most recent studies about treatment efficacy in neck pain, published in first quartile journals of the Journal Citation Reports, were selected. Females represented 67.5% of participants. A single study was of poor methodological quality (4/10). Based on the eligibility criteria of the articles that were systematically reviewed, it would appear that visceral aetiology was not considered in eighty percent of the trials on neck pain, showing a low level of suspicion both in research and clinical settings.

Surgical Rescue in Medical Patients: The Role of Acute Care Surgeons as the Surgical Rapid Response Team

Failure to rescue is death occurring after a complication. Rapid response teams developed as a prompt intervention for patients with early clinical deterioration, generally from medical conditions or complications. Patients with surgical complications or surgical pathology require prompt evaluation and management by surgeons to avoid deterioration; this is surgical rescue. Patients in the medical intensive care unit may develop intra-abdominal pathology that requires expeditious operative intervention. Acute care surgeons should serve as the surgical rapid response team to help assess and manage these complex patients. Collaboration between intensivists and surgeons is essential to rescue patients from complications and surgical disease.

Splenic rupture following colon polypectomy: a case report and review of literature

Colonoscopy is a safe procedure performed routinely worldwide. Splenic rupture is a rare complication of colonoscopy with several reported cases since 1974. We report the first case of a complication in the Republic of Korea. The literature on this rare complication is also reviewed here, with focus on the analysis of risk, diagnosis, and treatment. A 77-year-old patient receiving oral aspirin underwent colonoscopy with polypectomy. After 24 hours, the patient experienced dizziness and hypotension. Colonoscopy was performed to exclude intestinal bleeding, which could be diagnosed with hemoperitoneum. A computed tomography scan showed copious abdominal free blood and a splenic rupture. An urgent splenectomy was performed, which was the recognized procedure of choice. Physicians should have greater awareness of the possibility of splenic rupture following colonoscopy in order to avoid delay of diagnosis and treatment for this life-threatening complication.

Laparascopic Splenectomy Due to Splenic Injury after Colonoscopy

Colonoscopy, which is routinely performed in diagnosis and treatment of colorectal disorders, is a reliable procedure. Its most frequent complications are bleeding and perforation. Splenic rupture is a very rarely met complication of colonoscopy, and delay in its diagnosis leads to increased morbidity and mortality. We presented a 69 years old female patient, who was diagnosed by computerized abdominal tomography, performed for her abdominal pain, which started following the colonoscopy. After 15 days of medical treatment and follow-up, laparoscopic splenectomy was performed one month after her colonoscopy. The patient was discharged on her 4(th) postoperative day, with uneventful recovery. In patients who have complaint of abdominal pain following colonoscopy, an intraabdominal pathological condition should be considered and computerized abdominal tomography should be performed. If there is no detected intraperitoneal bleeding, in other words, if there is a sub-capsular hematoma of the spleen, medical management by monitoring the vital signs may be preferred. Then, splenectomy should be performed at an appropriate time.

Operative management of splenic rupture and hepatic flexure injury during diagnostic colonoscopy in a patient with adenocarcinoma of the cecum

Diagnostic colonoscopy has evolved to become the gold standard for the screening for carcinoma and other diseases of the colon. Injuries to the colon are rare and may be managed in a variety of ways. This includes observation and bowel rest or operative intervention and repair. Other organs are at risk during colonoscopy. The present report describes a patient who underwent colonoscopy for the work-up of anaemia. Following colonoscopy she developed signs of haemorrhagic shock and was found to have haemoperitoneum. She underwent surgery, and adenocarcinoma of the cecum was identified and managed during exploration. The clinical management is described.

Presentation and management of splenic injury after colonoscopy: a systematic review

This study reviewed all single experience of splenic injuries after colonoscopy in the last 40 years to define the possible risk factors and the management of this complication. A MEDLINE and a PubMed search was undertaken to identify articles in English, French, Spanish, and Italian from 1974 to 2012 using the key words: "splenic injury," "splenic rupture," and "colonoscopy." Data were analyzed using descriptive statistic. A total of 103 cases have been described in 75 reports. The majority of the patients were women (71.56%) and 6.85% underwent previous pelvic surgery. The mean age was 63 years (range, 29 to 90 y). About 61 of the 103 studies (59.2%) reported the presence or the absence of previous abdominal surgery and within these, only 31 of 61 patients (50.82%) underwent previous abdominal surgery. In this review, over half of the patients with splenic injury underwent colonoscopy for routine surveillance (62.75%), and only one third of the splenic injures were associated with biopsy or polypectomy. The majority of patients (78.57%) developed symptoms within the first 24 hours after colonoscopy and in a minority of cases (21.43%), there was a delayed presentation 24 hours after colonoscopy. Computed tomography was used as the primary modality to make the diagnosis in 69 of 98 cases (70.41%) and as a confirmatory test in many additional cases. Twenty-six of 102 patients (25.49%) were treated by conservative methods, whereas the majority of patients (69.61%) underwent splenectomy as a definitive treatment. Because of possible medicolegal implications, the endoscopists should consider mentioning splenic injury on the consent form of colonoscopy after bowel perforation and bleeding, particularly in higher risk patients.

Hemoperitoneum due to Splenic Laceration Caused by Colonoscopy: A Rare and Catastrophic Complication

Numerous studies suggest that in asymptomatic patients, routine follow-up CT is not indicated due to the insignificant findings found on these patients. A 53-year-old man, who denied any underlying disease before, underwent colonoscopy for routine health examination. Sudden onset of abdominal pain around left upper quarter was mentioned at our emergency department. Grade II spleen laceration was found on CT scan. Splenic injury was found few hours later on the day of colonoscopy. It might result from the extra tension between the spleen and splenic flexure which varies from different positions of patients.

Syncope as the presenting feature of splenic rupture after colonoscopy

Splenic rupture is a rare, catastrophic complication of colonoscopy and an exceptional cause of syncope. This injury is believed to be from direct trauma or tension on the splenocolic ligament with subsequent capsule avulsion or else from direct instrument-induced splenic injury. Diagnosis requires a high index of suspicion that may be absent because presentation can be subtle, nonspecific, and delayed anywhere from hours to days and therefore not easily attributed to a recent endoscopy. We describe a case of syncope as the initial manifestation of splenic rupture after colonoscopy. Our patient's pain was delayed; his discomfort was mild and not localized to the left upper quadrant. Clinicians should consider syncope, lightheadedness, and drop in hemoglobin in absence of rectal bleeding following a colonoscopy as possible warning signs of imminent or emergent splenic injury.

Is non-operative management feasible for splenic injury due to colonoscopy?

Colonoscopy is a widely used diagnostic and therapeutic procedure. While it is a relatively safe procedure, there is a risk of some complications. Splenic injury after colonoscopy is a very rare but a life-threatening complication; around 105 cases have been reported in the literature so far. Owing to the rarity of this complication, no management standards were defined. In the literature, most of the patients were managed with operative intervention and less frequently with observation. We report a case of splenic injury and massive hemoperitoneum due to colonoscopy treated non-operatively.

Endovascular treatment of active splenic bleeding after colonoscopy: a systematic review of the literature

PURPOSE

Colonoscopy is reported to be a safe procedure that is routinely performed for the diagnosis and treatment of colorectal diseases. Splenic rupture is considered to be a rare complication with high mortality and morbidity that requires immediate diagnosis and management. Nonoperative management (NOM), surgical treatment (ST), and, more recently, proximal splenic artery embolization (PSAE) have been proposed as treatment options. The goal of this study was to assess whether PSAE is safe even in high-grade ruptures.

METHODS

We report two rare cases of post colonoscopy splenic rupture. A systematic review of the literature from 2002 to 2010 (first reported case of PSAE) was performed and the three types of treatment compared.

RESULTS

All patients reviewed (77 of 77) presented with intraperitoneal hemorrhage due to isolated splenic trauma. Splenic rupture was high-grade in most patients when grading was possible. Six of 77 patients (7.8 %) were treated with PSAE, including the 2 cases reported herein. Fifty-seven patients (74 %) underwent ST. NOM was attempted first in 25 patients with a high failure rate (11 of 25 [44 %]) and requiring a salvage procedure, such as PSAE or ST. Previous surgery (31 of 59 patients), adhesions (10 of 13), diagnostic colonoscopies (49 of 71), previous biopsies or polypectomies (31 of 57) and female sex (56 of 77) were identified as risk factors. In contrast, splenomegaly (0 of 77 patients), medications that increase the risk of bleeding (13 of 30) and difficult colonoscopies (16 of 51) were not identified as risk factors. PSAE was safe and effective even in elderly patients with comorbidities and those taking medications that increase the risk of bleeding, and the length of the hospital stay was similar to that after ST.

CONCLUSION

We propose a treatment algorithm based on clinical and radiological criteria. Because of the high failure rate after NOM, PSAE should be the treatment of choice to manage grade I through IV splenic ruptures after colonoscopy in hemodynamically stabilized patients.

613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review

BACKGROUND

Rupture of the spleen in the absence of trauma or previously diagnosed disease is largely ignored in the emergency literature and is often not documented as such in journals from other fields. We have conducted a systematic review of the literature to highlight the surprisingly frequent occurrence of this phenomenon and to document the diversity of diseases that can present in this fashion.

METHODS

Systematic review of English and French language publications catalogued in Pubmed, Embase and CINAHL between 1950 and 2011.

RESULTS

We found 613 cases of splenic rupture meeting the criteria above, 327 of which occurred as the presenting complaint of an underlying disease and 112 of which occurred following a medical procedure. Rupture appeared to occur spontaneously in histologically normal (but not necessarily normal size) spleens in 35 cases and after minor trauma in 23 cases. Medications were implicated in 47 cases, a splenic or adjacent anatomical abnormality in 31 cases and pregnancy or its complications in 38 cases. The most common associated diseases were infectious (n = 143), haematologic (n = 84) and non-haematologic neoplasms (n = 48). Amyloidosis (n = 24), internal trauma such as cough or vomiting (n = 17) and rheumatologic diseases (n = 10) are less frequently reported. Colonoscopy (n = 87) was the procedure reported most frequently as a cause of rupture. The anatomic abnormalities associated with rupture include splenic cysts (n = 6), infarction (n = 6) and hamartomata (n = 5). Medications associated with rupture include anticoagulants (n = 21), thrombolytics (n = 13) and recombinant G-CSF (n = 10). Other causes or associations reported very infrequently include other endoscopy, pulmonary, cardiac or abdominal surgery, hysterectomy, peliosis, empyema, remote pancreato-renal transplant, thrombosed splenic vein, hemangiomata, pancreatic pseudocysts, splenic artery aneurysm, cholesterol embolism, splenic granuloma, congenital diaphragmatic hernia, rib exostosis, pancreatitis, Gaucher's disease, Wilson's disease, pheochromocytoma, afibrinogenemia and ruptured ectopic pregnancy.

CONCLUSIONS

Emergency physicians should be attuned to the fact that rupture of the spleen can occur in the absence of major trauma or previously diagnosed splenic disease. The occurrence of such a rupture is likely to be the manifesting complaint of an underlying disease. Furthermore, colonoscopy should be more widely documented as a cause of splenic rupture.

Splenic injury during colonoscopy--a complication that warrants urgent attention

INTRODUCTION

Colonoscopy is a safe procedure that is performed routinely worldwide. There is, however, a small but significant risk of splenic injury that is often under-recognized. Due to a lack of awareness about this injury, the diagnosis may be delayed, which can lead to an increased risk of morbidity as well as mortality. This paper presents a comprehensive review of the medical literature on colonoscopy-associated splenic injury and describes the clinical presentation and management of this rare but potentially life-threatening complication.

MATERIALS AND METHODS

A comprehensive literature search identified 102 patients worldwide, including patients from our experience, with splenic injury during colonoscopy. A meta-regression analysis was completed using a mixed generalized linear model for repeated measures to identify risk factors for this rare complication.

RESULTS

A total of 75 articles were identified and 102 patients were studied. The majority of the papers were in English (92 %). Only 23.4 % of patients (26/102) were reported prior to the year 2000. Among the patients reported after the year 2000, the majority (84.2 %, 64/76) were reported after 2005. There were more females (76.5 %), median age was 65 years (range, 29-90 years), and most of the colonoscopies were performed without difficulty (66.6 %). Nearly 67 % of patients presented within 24 h of colonoscopy with complaints ranging from abdominal pain to dizziness. The most common symptom was left upper quadrant pain (58 %), and CT scan was found to be the most sensitive tool for diagnosis. Seventy-three patients underwent operative intervention; 96 % of these were treated with splenectomy. Hemoglobin drop of more than 3 gm/dL was identified as the only significant predictor of operative intervention. The overall mortality rate was 5 %.

CONCLUSION

Splenic injury during colonoscopy is rare; however, it is associated with significant morbidity and mortality. Splenic injury warrants a high degree of clinical suspicion critical to prompt diagnosis, and early surgical consultation is warranted.

Medico-legal considerations in a case of splenic injury that occurred during colonoscopy

Colonoscopy has became the gold standard diagnostic and therapeutic treatment for rectum and colon diseases. The splenic injury is a rare complication of colonoscopy and relatively few cases (less than 70) have been reported in the literature so far. Here we present a case of splenic rupture identified in an 80 year-old man few hours after an apparently uneventful colonoscopy. Acknowledging a causal relationship between the lesion and the diagnostic procedures, we discuss the possible medico-legal implications with regard to professional liability considering the exceptional nature of such an event and the stance recently taken by the Italian law.

Splenic injury from colonoscopy: a review and management guidelines

Splenic injury is an uncommon complication of colonoscopy. Less than 100 cases are reported in the English language literature. The exact mechanism of injury to the spleen during colonoscopy is unknown; various authors propose several risk factors and possible mechanisms. Splenic injury can be graded or classified according to the extent of laceration and the severity of the resultant hematoma. The management options range from observation to emergency splenectomy. Computed tomography scan is the most important imaging modality to diagnose splenic injury. Early recognition and appropriate management is of paramount importance in the management of this condition. A high index of suspicion in a patient with persistent abdominal pain after colonoscopy is key especially when a perforated viscous is ruled out. This article outlines the clinical presentation of splenic injury after colonoscopy and delineates a management algorithm.

Splenic injury due to colonoscopy: nursing considerations

Complications associated with the performance of a colonoscopy are low. Splenic tearing or trauma postcolonoscopy is a rare but serious complication. Identification of a splenic injury is difficult because of the nonspecific nature of the patient's symptoms. A meta-analysis approach was used to identify common risk factors, onset and presentation of symptoms, and procedural difficulty associated with splenic injury postcolonoscopy. A review of 10 published case studies and 1 case presented by the author were compared with published findings for patients sustaining a splenic injury following colonoscopy. Potential common signs and symptoms as well as common risks factors were identified. Nursing considerations for the identification of high-risk patients and postprocedure symptoms are outlined. Early detection of this rare complication is difficult, but having a high level of suspicion can help to identify patients at risk for sustaining a splenic injury during colonoscopy.

Delayed presentation of splenic rupture following colonoscopy: clinical and CT findings

The purpose of this study is to investigate the clinical and CT findings in patients with symptomatic colonoscopy-induced splenic rupture, and to assess for common features among this cohort. Multi-center search yielded 11 adults with symptomatic splenic injury related to colonoscopy. Workup included abdominal CT in 10 (91%) cases and abdominal radiography in two patients (one patient had both). Colonoscopy findings, post-procedural course, and CT findings were systematically reviewed. Mean patient age was 62.2 years (range, 51-84 years); 8 (73%) of 11 were female. The majority (64%) of colonoscopies were for screening. No immediate complications were reported at optical colonoscopy; tortuosity/redundancy was noted in five cases. Except for a small (8 mm) polyp in one case and a large (10 mm) polyp in another, the remaining nine patients had either diminutive or no polyps. Only one patient presented with hemodynamic instability during post-colonoscopy recovery; the other ten had a delayed presentation ranging from 8 h to 8 days (mean, 2.1 days). All 11 patients presented with abdominal pain. CT was diagnostic for splenic injury with subcaspular and/or perisplenic hematoma in all ten CT cases. Hemoperitoneum was present in eight, visible splenic laceration in three cases, and splenic artery pseudoaneurysm in one case. Five patients underwent splenectomy (four emergent) and six patients were treated conservatively. Average hospital stay was 5.5 days (range, 3-10 days). Colonoscopy-induced splenic rupture characteristically presents as a delayed and often serious complication. In cases of apparent non-traumatic splenic hematoma or rupture at CT, eliciting a history of recent colonoscopy may identify the etiology.

Delayed presentation of splenic injury following diagnostic colonoscopy

Splenic injury (SI) is a rare complication after colonoscopy, but should be considered in the differential diagnosis of acute abdominal pain following this procedure. We report a case of delayed rupture and review pertinent literature. A 70-year-old patient on oral warfarin intake underwent colonoscopy that diagnosed obstructive rectal cancer and elongated colon conditioning the endoscope's passage. After 48 h, patient experienced sharp abdominal pain with mild peritoneal signs. Contrast-enhanced CT scan evidenced large amount of abdominal-free blood collection from grade II SI. Hypovolemic shock occurred following brief clinical observation. Urgent laparotomic splenectomy and contextual Hartmann's procedure were then carried out. Postoperative course was uneventful and definitive histology confirmed splenic subcapsular haematoma and locally advanced adenocarcinoma. Perforation and bleeding more likely occurred after colonoscopy, while few cases of SI are reported in literature since 1974. Traction on the splenocolic ligament and direct trauma has been advocated as possible causes. Peritoneal adhesions and splenic diseases usually are predisposing factors although not confirmed in our patient. Anticoagulant therapy favoured delayed filling up of subcapsular haematoma while bowel obstruction added further surgical challenge. Rapid onset of hemorrhagic shock required urgent splenectomy that remains the procedure of choice among the literature reviewed.

Splenic rupture after uncomplicated colonoscopy

Colonoscopy is a commonly performed medical procedure generally considered safe and effective. Rare complications include postpolypectomy bleeding and perforation. A far less common and more unusual complication is splenic injury. We present the case of a patient who developed this very outcome, presenting to the emergency department with abdominal pain several hours after the procedure. The mechanism of such injury is not known but has been hypothesized to be either traction on the splenocolic ligament or previously formed adhesions, direct blunt injury, or special maneuvers used to advance the colonoscope. Patients typically present with severe abdominal pain less than 24 hours after the procedure and may demonstrate Kehr's sign. Computed tomographic imaging is the diagnostic method of choice, and suspicion of splenic injury should necessitate careful observation with potential for operative intervention.

Splenic laceration following routine colonoscopy

Colonoscopy is a routine procedure done tens of thousands of times per year for screening purposes. The vast majority of these procedures are uneventful. There are, however, complications that can arise from this procedure, including hollow viscus perforation and hemorrhage. We present a case in which a lesser known complication of colonoscopy-splenic laceration-was cared for in our emergency department. This complication is unusual and not often cited in the literature, but is important to recognize and treat quickly. We present a case of a 67-year-old female who underwent a routine screening colonoscopy at our institution and presented to the emergency department several hours later complaining of abdominal pain. Ultimately, abdominal computed tomography showed a large splenic laceration, which was treated operatively. The diagnosis of splenic laceration should be considered for patients with continued abdominal pain post-colonoscopy when other etiologies have been evaluated and ruled out.

Two rare cases of spontaneous splenic rupture

The rupture of the spleen, not secondary to external trauma, is rare. Two cases are reported. The first case occurred in a patient with an aggressive form of lymphoma, and the second in a patient following a colonoscopy. In the rare occurrences of spontaneous rupture, radiological imaging, in particular by computed tomography, will lead to the diagnosis and help in deciding the correct treatment.

Splenic rupture after colonoscopy: a case report

Iatrogenic splenic tear after a colonoscopy is a rare complication. Conditions predisposing to splenocolic adhesions such as previous abdominal surgery, pancreatitis, or inflammatory bowel disease may increase the risk of this injury after colonoscopy. We present a case of a 47-year-old woman with an iatrogenic splenic tear after a routine colonoscopy, who had several of these predisposing factors and required an urgent splenectomy.

Splenic injury following colonoscopy--an underdiagnosed, but soon to increase, phenomenon?

INTRODUCTION

We present a case of splenic rupture in a 71-year-old woman admitted 6 days following a diagnostic colonoscopy. She underwent an open splenectomy and made a delayed, but complete, recovery. We proceeded to perform a retrospective review of all relevant literature to assess the frequency of similar post-colonoscopy complications.

MATERIALS AND METHODS

Using relevant keywords, we identified 63 further PubMed reports of splenic injury associated with colonoscopy that were reported in English.

FINDINGS

We have described only the fourth report of splenic injury secondary to colonoscopy from a UK centre. Literature review reveals a mean age of 63 years and a female preponderance for this complication. Most patients present on the day of their colonoscopy with abdominal pain, anaemia, elevated white cell count and Kehr's sign. CT is the investigation of choice and splenectomy the definitive management of choice. Most patients make a routine recovery, with mortality rates of approximately 8%. There is likely to be an under-reporting of this complication from UK-based centres, with the majority of reports originating from Europe and US. This points to a possible under-diagnosis or under-recognition of this potentially fatal complication. The incidence of such post-colonoscopic complications may increase with the forthcoming introduction of the National Bowel Cancer Screening Programme.

Splenic injury in colonoscopy: a review

INTRODUCTION

Splenic rupture secondary to colonoscopy was first reported in 1974 by Wherry and Zehner. It has an incidence of around 0.00005-0.017%, and a mortality rate of 5%.

METHOD

We performed a literature search to identify the demographic profile, risk factors, clinical presentations, diagnosis and management of this rare complication.

RESULTS

There were 66 patients (51 females and 14 males), with a median age of 65. The mortality rate was 4.5%. Majority (n=41, 62.1%) occurred in uneventful colonoscopies. Symptoms usually (74%) occurred within 24h, and 55.8% presented within 24h. Majority (93.9%) had some form of work-up done, with blood tests (78.8%) and CT (68.2%) being the most frequent. Laparotomy and splenectomy were done in over half (56.1%) of the patients. Splenic hematoma (47%), laceration (47%) and rupture (33.3%) were the most common findings.

CONCLUSION

Splenic injury is an important complication to be aware of as its number will continue to rise with the increasing numbers of colonoscopies being performed for colorectal diseases, and delayed diagnosis may result in adverse outcome for the patient.